When to refer to social worker?

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Hi everyone! I was wondering if I could get some advice regarding when to refer a patient to a social worker. I currently do the admissions, just started home care in June. I'm struggling when it is appropriate to refer my patients for a social worker. For example, I had a patient today who is elderly, lives alone in 2 story condo, no children. Drives, but not often, probably shouldn't even be driving in the first place....but anyways, we are in for care to ulcer on her foot. Unclear when I asked who does her food shopping ect...declines HHA. Appropriate for social work eval?

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I would order an eval on this patient to see if he qualifies for community resources. I'm big on MSW evaluations. Medicare likes them too because it shows that the agency has followed through on the problems. These are some of the reasons I order a MSW consult:

Patient needs Meals on Wheels or other community resources
Pt does not have an Advance Directive (everyone needs one)
Pt does not have a caregiver
Pt cannot afford his medication, food, rent, etc
Patient scores anything but 0 on the depression screening
Patient may qualify for Medicaid
The environment is not safe for the patient
Problem with family dynamics

Remember, if MSW is not already ordered, you have to call the physician and get an order. If you think the patient should have a MSW consult and they refuse, may sure to document that!